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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PEMIT EXPIRES 1 I DATE I.SSUBD <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or inetall the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and .1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> Job Address O a City Lot Size/Acreage <br /> Owner's Name Address Phone <br /> • <br /> Contra Addre No, <br /> Phonea�62 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ <br /> ` PUMP INSTALLATION �• SYSTEM REPAIR 0 _ OTHER,C7�_ Monitoring Well <br /> "'—DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. �.-". PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Indu al ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omesticlPrivate 0 Gravel Pack 0 Tracy r Type of Casing Specifications <br /> ID Public C1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> Cl Irrigation _Approx. Oe th Eastern Surface Seal Installed by <br /> Repair Work Done WOO' Type of PumpH.P. 4EI`! --- . _ State Work Done <br /> Well Destruction O Well Diameter ___ Sealing Material i Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION G Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other r <br /> Number of living units: - Number of bedrooms r <br /> Character of soil to a depth of 3 feat: Water table depth <br /> �,-:SEPTiC TANK ❑ Type/Mfg Capacity No. Compartrrrents <br /> PKG. TREATMENT PLT.[1 Method of Disposal T <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED 11 Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number �. <br /> SUMPS _ Ll #Distance to nearest: Well Foundation Property Line A YA# <br /> coy <br /> DISPOSAL PONDS © E !�J, <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinajr sCstat 9 Z <br /> rules and regulations of the San Joaquin.County R�iCC ���� <br /> Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this ps" i ed, 'Neal <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiringRU68 WIN <br /> "l <br /> certifies the following: certify that in the performance of the work for which this permit is issued, I shall employ persons s ij" r <br /> ly <br /> tion laws of California." TAL HEAL. <br /> The epplicant must 0A, 44oquired inspectio o'mpleie drawing o r ree side. Q1 <br /> Signed X Date: <br /> FOR DEPARTMENT USE ONLY 1 l <br /> Application Accepted by _ ni Date , L .Area <br /> Pit or Grout Inspection by Date Final Inspection by Date�Z 6 <br /> Additional Comments: — <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O,BO 008, STOCKTON, CA 85201 <br /> r FEE AMOUNT DUE AMOUNT REMITTED' , "CK EIVED BY DAIE PERMIT'N0. <br /> INFO <br /> . EH 13.241REv.iinsl J��G '(� <br /> EH tb2a f 1 V <br />